Articoli di riviste sul tema "Mae La (Thailand : Refugee camp)"

This study presents data on consumption patterns, methods of food procurement, and adequacy of dietary intake among Burmese refugee camp households living along Thailand's border with Burma. Households established for one or more years and with children under 15 years of age were sampled. A questionnaire was used to determine economic, food-consumption, and dietary intake patterns; foods consumed were weighed and measured using a 24-hour recall for the household unit; and nutritional status was determined by a Microtoise tape and digital standing scales. In total, 182 households containing 1,159 people were surveyed. The average household energy and protein intakes were 96.6% and 111.4%, respectively, of the recommended daily allowance (RDA) for healthy Thais. Twelve percent of protein was derived from animal sources. Carbohydrate, protein, and fat accounted for 84%, 9%, and 7% of total energy, respectively. The intake of vitamins A, B1, B2, and C and of calcium ranged from 24.2% to 53.1% of the RDA. Iron intake was 85.3% of the RDA, derived mainly from rice, fermented fish, mung beans, green leafy vegetables, and eggs. Ration foods supplied 60.5% to 98.18% of all nutrients consumed in the households, with the exception of vitamins A and C. Among children under five years of age, 33.7% were underweight, 36.4% were stunted, and 8.7% were wasted. Although the refugees were able to procure some nonration foods by foraging, planting trees and vegetables, raising animals, and purchasing and exchanging ration foods for other items, the quantity and quality were not sufficient to compensate for the nutrients that were low or lacking in the ration. The overwhelming majority of dietary nutrients were provided by ration foods, and although the ration and the overall diet may be adequate for short-term subsistence, they do not suffice for long-term survival and optimal growth, especially for younger children.

During the latter part of 1979, hundreds of thousands Kampuchean refugees fled from all parts of their war- and hunger-ridden country to the Thai-Cambodian border, thousands perishing from hunger, disease and stepping on mine fields on the way. The majority of those who survived settled in several large villages straddling the border in relative security from the advancing Vietnamese army, receiving food and medical supplies from many international welfare organizations.Widespread public interest in the plight of these refugees arose in Israel after a television program late in October 1979, and a public campaign initiated by Mr. Abie Nathan, an Israeli citizen. The ensuing fund-raising efforts resulted in 1.2 million dollars, most of which originated from private donations. These contributions enabled the Israeli government to equip 5 medical teams and send them to Thailand, covering the last two months of 1979 and the first 4 months of 1980.

The Khao I Dang Holding Center for Kampucheans opened November 21, 1979 as part of an effort to bring relief to the thousands of Cambodian on the eastern frontier of Thailand. The camp population increased from 4800 that first day to 50,000 by December 1, 1979 and 110,000 by mid-January, 1980. Sixty-one percent (61%) of the population were 15 years of age and older; 12% of these over 44. Thirty-nine percent (39%) were children under 15.Although each disaster is unique, the medical problems for a type of disaster in a stated area are considered predictable. This was not the case at Khao I Dang for hospital pysicians in providing patient care. It has been shown that relief efforts are amenable to study, yet such studies have been handicapped by a lack of data. Since major disasters involving international aid are reported several times a year, the problem is considerable.

Background: In Myanmar, formerly known as Burma, conflicts between ethnic minorities, the government, and the military have been ongoing for decades. Enduring unrest has caused thousands to flee to the region around Mae Sot, a city on Thailand’s western border. Women around the world assume a combination of reproductive and productive responsibilities, and during situations of armed conflict and displacement, conditions for women often worsen. This study investigated the parenting experiences of female migrants from Myanmar living in protracted refugee situations in Mae Sot. Methods: This research was part of a mixed-methods international comparative study on the experiences of parenting in adversity. In this analysis, 62 first-person qualitative narratives shared by migrant mothers in the Thailand–Myanmar border region were inductively analyzed using the Qualitative Analysis Guide of Leuven method. Results: The results highlight how migrant mothers undertake significant reproductive responsibilities, such as breastfeeding and child-rearing, as well as productive responsibilities, including paid labour in the agricultural, formal, and informal sectors. In order to care and provide for their families, female migrants in the Thailand–Myanmar border region utilized four childcare strategies: caring for children while working, caring for children instead of working, dispersing responsibilities amongst extended family members and children, and delegating reproductive responsibilities to formal and non-familial caretakers. Conclusions: Most mothers shared stories in which they or their immediate family members cared for their children, rather than depending on neighbours or formal childminders. Female migrants may face challenges locating desirable work that is compatible with childcare, rendering certain childcare arrangement strategies more prevalent than others. Further research could elucidate these challenges and how opportunities for gainful employment that are conducive to childcare can be generated for women living in protracted refugee situations.

Background: Diarrhoea cases make up nearly two-thirds of total clinic visits at Mae La temporary shelter, Thailand, 40% being under five diarrhoeal cases. The use of a safe storage container for drinking water may prevent contamination and reduce diarrhoeal disease morbidity in camp residents. The aim of this study was to evaluate the use of safe drinking water storage containers and diarrhoeal diseases in under 5 children at the Mae La temporary shelter. Methods: A randomized controlled trail was conducted in 400 households with at least one child under 5 years old over a period of four months. Intervention households received safe containers, while control households did not. Households were visited twice weekly during the three-month follow-up. Recent occurrence of diarrhoea in children under five was ascertained and residual chlorine levels in drinking water were measured. The results were analyzed by chi-square tests and survival analyses. Results: Overall, the study found a 75% reduction of under five diarrhoea in the intervention group and 3.5-times less risk than control group subjects. Key factors associated with under five diarrhoea were: study group participation, no formal education of household primary caregivers; main sources of acquired drinking water; awareness regarding tap water chlorination; length of time living in camp Conclusion: In conclusion, intervention group participants were found to experience a reduction in diarrhoea morbidity when compared to their control group counterparts. E. coli contamination of drinking water was very common, suggesting little or no protection from chlorination.

Background: Diarrhoea cases make up nearly two-thirds of total clinic visits at Mae La temporary shelter, Thailand, 40% being under five diar­rhoeal cases. The use of a safe storage container for drinking water may prevent contamination and reduce diarrhoeal disease morbidity in camp residents. The aim of this study was to evaluate the use of safe drinking water storage containers and diarrhoeal diseases in under 5 children at the Mae La temporary shelter. Methods: A randomized controlled trail was conducted in 400 households with at least one child under 5 years old over a period of four months. In­tervention households received safe containers, while control households did not. Households were visited twice weekly during the three-month follow-up. Recent occurrence of diarrhoea in children under five was as­certained and residual chlorine levels in drinking water were measured. The results were analyzed by chi-square tests and survival analyses. Results: Overall, the study found a 75% reduction of under five diarrhoea in the intervention group and 3.5-times less risk than control group sub­jects. Key factors associated with under five diarrhoea were: study group participation, no formal education of household primary caregivers; main sources of acquired drinking water; awareness regarding tap water chlori­nation; length of time living in camp Conclusions: In conclusion, intervention group participants were found to experience a reduction in diarrhoea morbidity when compared to their control group counterparts. E. coli contamination of drinking water was very common, suggesting little or no protection from chlorination.

COVID-19 pandemic becomes the major disaster happening through out every part of the world and change every single sector, including the humanitarian perspective. As the COVID-19 has spread, government worldwide restrict the movement of people, interruption on activists to deliver assistances, logistics challenge and hampering humanitarian responses. This article makes HUMANITARIAN CARE MALAYSIA BERHAD (MyCARE) as an example of a local Malaysian NGO in providing humanitarian assistance during the periods in the pandemic. MyCARE is a Non-Profit Organization (NPO) registered with the Companies Commission of Malaysia (SSM) [Reg. No: 729288-P], the member of South East Asia Humanitarian Communities (SEAHUM) and existing special consultative member of United Nations Economic and Social Council (ECOSOC).MyCARE’s humanitarian relief network covers South East Asia Archipelago including the Philippines, Cambodia, Southern Thailand and Vietnam; war-torn countries in the Middle East such as Palestine, Syria, Lebanon and Iraq; the stateless and displaced Rohingya people, as well as disaster-stricken areas regardless of racial and religious boundaries. MyCARE is also active in Malaysia in providing temporary shelters, rebuilding homes and provision of fresh water in the flood-stricken areas.This article wishes to share the humanitarian works by MyCARE, in which major assistance has been provided to a major natural hazard be affected during the COVID-19 pandemic in Malaysia, and urgent needs for countries such as Gaza and well as the Rohingya Refugee Camp in Cox’s Bazar, Bangladesh as the largest refugee camp in the world.International Journal of Human and Health Sciences Supplementary Issue: 2021 Page: S8

The extent to which evolution is constrained by the rate at which horizontal gene transfer (HGT) allows DNA to move between genetic lineages is an open question, which we address in the context of antibiotic resistance in Streptococcus pneumoniae. We analyze microbiological, genomic, and epidemiological data from the largest-to-date sequenced pneumococcal carriage study in 955 infants from a refugee camp on the Thailand-Myanmar border. Using a unified framework, we simultaneously test prior hypotheses on rates of HGT and a key evolutionary covariate (duration of carriage) as determinants of resistance frequencies. We conclude that in this setting, there is little evidence of HGT playing a major role in determining resistance frequencies. Instead, observed resistance frequencies are best explained as the outcome of selection acting on a pool of variants, irrespective of the rate at which resistance determinants move between genetic lineages.

ObjectiveTo describe neonatal survival and long-term neurological outcome in neonatal hyperbilirubinaemia (NH) with extreme serum bilirubin (SBR) values.DesignRetrospective chart review, a one-off neurodevelopmental evaluation.SettingSpecial care baby unit in a refugee camp and clinics for migrant populations at the Thailand–Myanmar border with phototherapy facilities but limited access to exchange transfusion (ET).PatientsNeonates ≥28 weeks of gestational age with extreme SBR values and/or acute neurological symptoms, neurodevelopment evaluation conducted at 23–97 months of age.Main outcome measuresNeonatal mortality rate, prevalence of acute bilirubin encephalopathy (ABE) signs, prevalence of delayed development scores based on the Griffiths Mental Development Scale (GMDS).ResultsFrom 2009 to 2014, 1946 neonates were diagnosed with jaundice; 129 (6.6%) had extreme SBR values during NH (extreme NH). In this group, the median peak SBR was 430 (IQR 371–487) µmol/L and the prevalence of ABE was 28.2%. Extreme NH-related mortality was 10.9% (14/129). Median percentile GMDS general score of 37 survivors of extreme NH was poor: 11 (2–42). ‘Performance’, ‘practical reasoning’ and ‘hearing and language’ domains were most affected. Four (10.8%) extreme NH survivors had normal development scores (≥50th centile). Two (5.4%) developed the most severe form of kernicterus spectrum disorders.ConclusionIn this limited-resource setting, poor neonatal survival and neurodevelopmental outcomes, after extreme NH, were high. Early identification and adequate treatment of NH where ET is not readily available are key to minimising the risk of extreme SBR values or neurological symptoms.

Background Soil-transmitted helminth (STH) infections are widespread in tropical and subtropical regions. While many STH infections are asymptomatic, vulnerable populations such as pregnant women face repercussions such as aggravation of maternal anaemia. However, data on prevalence and the effect of STH infections in pregnancy are limited. The aim of this analysis was to describe the burden of STH infections within and between populations of pregnant women from a local refugee camp to a mobile migrant population, and to explore possible associations between STH infection and pregnancy outcomes. Methodology This is a retrospective review of records from pregnant refugee and migrant women who attended Shoklo Malaria Research Unit antenatal care (ANC) clinics along the Thailand-Myanmar border between July 2013 and December 2017. Inclusion was based on provision of a stool sample during routine antenatal screening. A semi-quantitative formalin concentration method was employed for examination of faecal samples. The associations between STH mono-infections and maternal anaemia and pregnancy outcomes (i.e., miscarriage, stillbirth, preterm birth, and small for gestational age) were estimated using regression analysis. Principal findings Overall, 12,742 pregnant women were included, of whom 2,702 (21.2%) had a confirmed infection with either Ascaris lumbricoides, hookworm, Trichuris trichiura, or a combination of these. The occurrence of STH infections in the refugee population (30.8%; 1,246/4,041) was higher than in the migrant population (16.7%; 1,456/8,701). A. lumbricoides was the predominant STH species in refugees and hookworm in migrants. A. lumbricoides and hookworm infection were associated with maternal anaemia at the first ANC consultation with adjusted odds ratios of 1.37 (95% confidence interval (CI) 1.08–1.72) and 1.65 (95% CI 1.19–2.24), respectively. Pregnant women with A. lumbricoides infection were less likely to miscarry when compared to women with negative stool samples (adjusted hazard ratio 0.63, 95% CI 0.48–0.84). STH infections were not significantly associated with stillbirth, preterm birth or being born too small for gestational age. One in five pregnant women in this cohort had STH infection. Association of STH infection with maternal anaemia, in particular in the event of late ANC enrolment, underlines the importance of early detection and treatment of STH infection. A potential protective effect of A. lumbricoides infection on miscarriage needs confirmation in prospective studies.

SummarySeveral years ago the Walter Reed Army Institute of Research (WRAIR) initiated an independent analysis of the candidate malaria blood stage vaccine SPf66. WRAIR contracted for the synthesis and formulation of SPf66 in United States Food and Drug Administration (FDA) inspected laboratories within the U.S., and in 1992, filed an Investigational New Drug (IND) application with the FDA. Preclinical studies indicated that the vaccine could be synthesized to meet its release specifications, and when adjuvanted with alum, was essentially equivalent to Colombian produced SPf66 in regards to immunogenicity in preclinical studies of rodents and primates, and in human volunteers in Phase I studies. The goal of these efforts was ultimately to conduct a Phase IIb field trial to determine the safety and efficacy of SPf66 produced under current Good Manufacturing Practices (cGMP). Such a trial is currently underway in a malaria endemic refugee camp along the Thai–Burmese border. Here we briefly describe the study and present the formal analytic plan that was submitted to regulatory authorities in the United States for analysis of the study results. We believe such independent confirmatory studies are an essential part of the vaccine development process and are required to provide important data regarding the safety and efficacy of candidate vaccines in diverse geographical regions, and as a means to assess their role in the context of broader malaria control programmes.

Background A global stockpile of oral cholera vaccine (OCV) was established in 2013 for use in outbreak response and are licensed as two-dose regimens. Vaccine availability, however, remains limited. Previous studies have found that a single dose of OCV may provide substantial protection against cholera. Methods Using a mathematical model with two age groups paired with optimization algorithms, we determine the optimal vaccination strategy with one and two doses of vaccine to minimize cumulative overall infections, symptomatic infections, and deaths. We explore counterfactual vaccination scenarios in three distinct settings: Maela, the largest refugee camp in Thailand, with high in- and out-migration; N’Djamena, Chad, a densely populated region; and Haiti, where departments are connected by rivers and roads. Results Over the short term under limited vaccine supply, the optimal strategies for all objectives prioritize one dose to the older age group (over five years old), irrespective of setting and level of vaccination coverage. As more vaccine becomes available, it is optimal to administer a second dose for long-term protection. With enough vaccine to cover the whole population with one dose, the optimal strategies can avert up to 30% to 90% of deaths and 36% to 92% of symptomatic infections across the three settings over one year. The one-dose optimal strategies can avert 1.2 to 1.8 times as many cases and deaths compared to the standard two-dose strategy. Conclusions In an outbreak setting, speedy vaccination campaigns with a single dose of OCV is likely to avert more cases and deaths than a two-dose pro-rata campaign under a limited vaccine supply.

A critical remote sensing approach illuminates the geopolitics of development within Myanmar and across its ethnic minority borderlands. By integrating nighttime light (NTL) data from 1992–2020, long-term ethnographic fieldwork, and a review of scholarly and gray literature, we analyzed how Myanmar’s economic geography defies official policy, attesting to persistent inequality and the complex relationships between state-sponsored and militia-led violence, resource extraction, and trade. While analysis of DMSP-OLS data (1992–2013) and VIIRS data (2013–2020) reveals that Myanmar brightened overall, especially since the 2010s in line with its now-halting liberalization, growth in lights was unequally distributed. Although ethnic minority states brightened more rapidly than urbanized ethnic majority lowland regions, in 2020, the latter still emitted 5.6-fold more radiance per km2. Moreover, between 2013 and 2020, Myanmar’s borderlands were on average just 13% as bright as those of its five neighboring countries. Hot spot analysis of radiance within a 50 km-wide area spanning both sides of the border confirmed that most significant clusters of light lay outside Myanmar. Among the few hot spots on Myanmar’s side, many were associated with official border crossings such as Muse, the formal hub for trade with China, and Tachileik and Myawaddy next to Thailand. Yet some of the most significant increases in illumination between 2013 and 2020 occurred in areas controlled by the Wa United State Party and its army, which are pursuing infrastructure development and mining along the Chinese border from Panghsang to the illicit trade hub of Mongla. Substantial brightening related to the “world’s largest refugee camp” was also detected in Bangladesh, where displaced Rohingya Muslims fled after Myanmar’s military launched a violent crackdown. However, no radiance nor change in radiance were discernible in areas within Myanmar where ethnic cleansing operations occurred, pointing to the limitations of NTL. The diverse drivers and implications of changes in light observed from space emphasize the need for political and economically situated remote sensing.

This article reflects on how offline and online everyday life coexists for encamped, young Karen living in protracted displacement. As part of the special issue ‘Cultures of (im)mobile entanglements’, edited by Earvin Cabalquinto and Koen Leurs, I centre the voices of young Karen living in Mae La refugee camp in Thailand and unpack how personal and social relationships are built and maintained physically in the camp, as well as in digitally mediated spaces. I focus on the tensions of (im)mobility and how life and presence were mediated before and during the Covid-19 pandemic. I emphasise the influence of culture, society, and infrastructure on my participants’ living trajectories and find how social media expands their lived reality far beyond the confinement of the camp.

Abstract This article reports on a longitudinal case study, which included site visits in Thailand from 2014 to 2015, and participant follow-up to mid-2018. It documents the lived experience of children from Syria, Sri Lanka, Pakistan, Vietnam, and Myanmar in two different locations in Thailand: Bangkok and Mae Sot (a district close to Thailand-Myanmar border with a long history of economic migrants and refugees from Myanmar). It documents perspectives of children and the adults in their lives while in exile. It presents an analysis of the children’s perspectives on needs and how unmet needs for safety, basic materials, health care, and education put them at risk of arrest, detention, abuse, and exploitation, and impact their psychological development. Contextual factors such as available services, existing policies and laws are also discussed in relation to the Convention on the Rights of the Child (CRC).

Abstract Background Cholera is a major public health concern in displaced-person camps, which often contend with overcrowding and scarcity of resources. Maela, the largest and longest-standing refugee camp in Thailand, located along the Thai-Burmese border, experienced four cholera outbreaks between 2005 and 2010. In 2013, a cholera vaccine campaign was implemented in the camp. To assist in the evaluation of the campaign and planning for subsequent campaigns, we developed a mathematical model of cholera in Maela. Methods We formulated a Susceptible-Infectious-Water-Recovered-based transmission model and estimated parameters using incidence data from 2010. We next evaluated the reduction in cases conferred by several immunization strategies, varying timing, effectiveness, and resources (i.e., vaccine availability). After the vaccine campaign, we generated case forecasts for the next year, to inform on-the-ground decision-making regarding whether a booster campaign was needed. Results We found that preexposure vaccination can substantially reduce the risk of cholera even when <50% of the population is given the full two-dose series. Additionally, the preferred number of doses per person should be considered in the context of one vs. two dose effectiveness and vaccine availability. For reactive vaccination, a trade-off between timing and effectiveness was revealed, indicating that it may be beneficial to give one dose to more people rather than two doses to fewer people, given that a two-dose schedule would incur a delay in administration of the second dose. Forecasting using realistic coverage levels predicted that there was no need for a booster campaign in 2014 (consistent with our predictions, there was not a cholera epidemic in 2014). Conclusions Our analyses suggest that vaccination in conjunction with ongoing water sanitation and hygiene efforts provides an effective strategy for controlling cholera outbreaks in refugee camps. Effective preexposure vaccination depends on timing and effectiveness. If a camp is facing an outbreak, delayed distribution of vaccines can substantially alter the effectiveness of reactive vaccination, suggesting that quick distribution of vaccines may be more important than ensuring every individual receives both vaccine doses. Overall, this analysis illustrates how mathematical models can be applied in public health practice, to assist in evaluating alternative intervention strategies and inform decision-making.

There are many reasons to pursue professional development, but perhaps one of the most importantmay be to narrow the wide chasm left behind by many teacher education programs. Freeman (1989)and Holliday (1994) have pointed out many of the difficulties associated with the transfer of knowledgeinto classroom practices, while others have directed attention to the vast kaleidoscope of culturaldiversity involved in ELT (see Larsen-Freeman, 1983; Colabucci, 2007; Govardhan, Nayar andSheorey, 1999). Consider, for a moment, what happens to a cohort of MA TESOL students uponcompletion of their teacher education programs. They scatter off to various points on the globe, each insearch of a job with their newly minted degrees. One could end up teaching at a refugee camp in ruralnorthern Thailand, with only chalk and a blackboard at their disposal, while another may end upteaching EAP in the United Arab Emirates. Given such diversity, then, how could any one teachereducation program ever prepare its students to meet such challenges?

Abstract Aim: The study assessed mothers, children and adolescents’ health (MCAH) outcomes in the context of a Primary Health Care (PHC) project and associated costs in two protracted long-term refugee camps, along the Thai-Myanmar border. Background: Myanmar refugees settled in Thailand nearly 40 years ago, in a string of camps along the border, where they fully depend on external support for health and social services. Between 2000 and 2018, a single international NGO has been implementing an integrated PHC project. Methods: This retrospective study looked at the trends of MCAH indicators of mortality and morbidity and compared them to the sustainable development goals (SDGs) indicators. A review of programme documents explored and triangulated the evolution and changing context of the PHC services, and associated project costs were analysed. To verify changes over time, interviews with 12 key informants were conducted. Findings: While maternal mortality (SDG3.1) remained high at 126.5/100,000 live births, child mortality (SDG 3.2) and infectious diseases in children under 5 (SDG 3.3) fell by 69% and by up to 92%, respectively. Maternal anaemia decreased by 30%; and more than 90% of pregnant women attended four or more antenatal care visits, whereas 80% delivered by a skilled birth attendant; caesarean section rates rose but remained low at an average of 3.7%; the adolescent (15–19 years) birth rate peaked at 188 per 1000 in 2015 but declined to 89/1000 in 2018 (SDG 3.7). Conclusion: Comprehensive PHC delivery, with improved health provider competence in MCAH care, together with secured funding is an appropriate strategy to bring MCAH indicators to acceptable levels. However, inequities due to confinement in camps, fragmentation of specific health services, prevent fulfilment of the 2030 SDG Agenda to ‘Leave no one behind’. Costs per birth was 115 EURO in 2018; however, MCAH expenditure requires further exploration over a longer period.

AbstractAccurate and reliable guidelines for referral of children from resource-limited primary care settings are lacking. We identified three practicable paediatric severity scores (the Liverpool quick Sequential Organ Failure Assessment (LqSOFA), the quick Pediatric Logistic Organ Dysfunction-2, and the modified Systemic Inflammatory Response Syndrome) and externally validated their performance in young children presenting with acute respiratory infections (ARIs) to a primary care clinic located within a refugee camp on the Thailand-Myanmar border. This secondary analysis of data from a longitudinal birth cohort study consisted of 3010 ARI presentations in children aged ≤ 24 months. The primary outcome was receipt of supplemental oxygen. We externally validated the discrimination, calibration, and net-benefit of the scores, and quantified gains in performance that might be expected if they were deployed as simple clinical prediction models, and updated to include nutritional status and respiratory distress. 104/3,010 (3.5%) presentations met the primary outcome. The LqSOFA score demonstrated the best discrimination (AUC 0.84; 95% CI 0.79–0.89) and achieved a sensitivity and specificity > 0.80. Converting the scores into clinical prediction models improved performance, resulting in ~ 20% fewer unnecessary referrals and ~ 30–50% fewer children incorrectly managed in the community. The LqSOFA score is a promising triage tool for young children presenting with ARIs in resource-limited primary care settings. Where feasible, deploying the score as a simple clinical prediction model might enable more accurate and nuanced risk stratification, increasing applicability across a wider range of contexts.

AbstractReliable tools to inform outpatient management of childhood pneumonia in resource-limited settings are needed. We investigated the value added by biomarkers of the host infection response to the performance of the Liverpool quick Sequential Organ Failure Assessment score (LqSOFA), for triage of children presenting with pneumonia to a primary care clinic in a refugee camp on the Thailand-Myanmar border. 900 consecutive presentations of children aged ≤ 24 months meeting WHO pneumonia criteria were included. The primary outcome was receipt of supplemental oxygen. We compared discrimination of a clinical risk score (LqSOFA) to markers of endothelial injury (Ang-1, Ang-2, sFlt-1), immune activation (CHI3L1, IP-10, IL-1ra, IL-6, IL-8, IL-10, sTNFR-1, sTREM-1), and inflammation (CRP, PCT), and quantified the net benefit of including biomarkers alongside LqSOFA. We evaluated the differential contribution of LqSOFA and host biomarkers to the diagnosis and prognosis of pneumonia severity. 49/900 (5.4%) presentations met the primary outcome. Discrimination of LqSOFA and Ang-2, the best performing biomarker, were comparable (AUC 0.82 [95% CI 0.76–0.88] and 0.81 [95% CI 0.74–0.87] respectively). Combining Ang-2 with LqSOFA improved discrimination (AUC 0.91; 95% CI 0.87–0.94; p < 0.001), and resulted in greater net benefit, with 10–30% fewer children who required oxygen supplementation incorrectly identified as safe for community-based management. Ang-2 had greater prognostic utility than LqSOFA to identify children requiring supplemental oxygen later in their illness course. Combining Ang-2 and LqSOFA could guide referrals of childhood pneumonia from resource-limited community settings. Further work on test development and integration into patient triage is required.

Introduction The term ‘resilience’ is on everyone’s lips - from politicians to community service providers to the seemingly endless supply of self-help gurus. The concept is undergoing a renaissance of sorts in contemporary Western society; but why resilience now? One possible explanation is that individuals and their communities are experiencing increased and intensified levels of adversity and hardship, necessitating the accumulation and deployment of ‘more resilience’. Whilst a strong argument could made that this is in fact the case, it would seem that the capacity to survive and thrive has been a feature of human survival and growth long before we had a name for it. Rather than an inherent characteristic, trait or set of behaviours of particularly ‘resilient’ individuals or groups, resilience has come to be viewed more as a common and everyday capacity, expressed and expressible by all people. Having researched the concept for some time now, we believe that we are only marginally closer to understanding this captivating but ultimately elusive concept. What we are fairly certain of is that resilience is more than basic survival but less than an invulnerability to adversity, resting somewhere in the middle of these two extremes. Given the increasing prevalence of populations affected by war and other disasters, we are certain however that efforts to better understand the accumulative dynamics of resilience, are now, more than ever, a vital area of public and academic concern. In our contemporary world, the concept of resilience is coming to represent a vital conceptual tool for responding to the complex challenges emerging from broad scale movements in climate change, rural and urban migration patterns, pollution, economic integration and other consequences of globalisation. In this article, the phenomenon of human resilience is defined as the cumulative build-up of both particular kinds of knowledge, skills and capabilities as well as positive affects such as hope, which sediment over time as transpersonal capacities for self-preservation and ongoing growth (Wilson). Although the accumulation of positive affect is crucial to the formation of resilience, the ability to re-imagine and utilise negative affects, events and environmental limitations, as productive cultural resources, is a reciprocal and under-researched aspect of the phenomenon. In short, we argue that resilience is the protective shield, which capacitates individuals and communities to at least deal with, and at best, overcome potential challenges, while also facilitating the realisation of hoped-for objects and outcomes. Closely tied to the formation of resilience is the lived experience of hope and hoping practices, with an important feature of resilience related to the future-oriented dimensions of hope (Parse). Yet it is important to note that the accumulation of hope, as with resilience, is not headed towards some state of invulnerability to adversity; as presumed to exist in the foundational period of psychological research on the construct (Garmezy; Werner and Smith; Werner). In contrast, we argue that the positive affective experience of hopefulness provides individuals and communities with a means of enduring the present, while the future-oriented dimensions of hope offer them an instrument for imagining a better future to come (Wilson). Given the complex, elusive and non-uniform nature of resilience, it is important to consider the continued relevance of the resilience concept. For example, is resilience too narrow a term to describe and explain the multiple capacities, strategies and resources required to survive and thrive in today’s world? Furthermore, why do some individuals and communities mobilise and respond to a crisis; and why do some collapse? In a related discussion, Ungar (Constructionist) posed the question, “Why keep the term resilience?” Terms like resilience, even strengths, empowerment and health, are a counterpoint to notions of disease and disorder that have made us look at people as glasses half empty rather than half full. Resilience reminds us that children survive and thrive in a myriad of ways, and that understanding the etiology of health is as, or more, important than studying the etiology of disease. (Ungar, Constructionist 91) This productive orientation towards health, creativity and meaning-making demonstrates the continued conceptual and existential relevance of resilience, and why it will remain a critical subject of inquiry now and into the future. Early Psychological Studies of Resilience Definitions of resilience vary considerably across disciplines and time, and according to the theoretical context or group under investigation (Harvey and Delfabro). During the 1970s and early 1980s, the developmental literature on resilience focused primarily on the “personal qualities” of “resilient children” exposed to adverse life circumstances (Garmezy Vulnerability; Masten; Rutter; Werner). From this narrow and largely individualistic viewpoint, resilience was defined as an innate “self-righting mechanism” (Werner and Smith 202). Writing from within the psychological tradition, Masten argued that the early research on resilience (Garmezy Vulnerability; Werner and Smith) regularly implied that resilient children were special or remarkable by virtue of their invulnerability to adversity. As research into resilience progressed, researchers began to acknowledge the ordinariness or everydayness of resilience-related phenomena. Furthermore, that “resilience may often derive from factors external to the child” (Luthar; Cicchetti and Becker 544). Besides the personal attributes of children, researchers within the psychological sciences also began to explore the effects of family dynamics and impacts of the broader social environment in the development of resilience. Rather than identifying which child, family or environmental factors were resilient or resilience producing, they turned their attention to how these underlying protective mechanisms facilitated positive resilience outcomes. As research evolved, resilience as an absolute or unchanging attribute made way for more relational and dynamic conceptualisations. As Luthar et al noted, “it became clear that positive adaptation despite exposure to adversity involves a developmental progression, such that new vulnerabilities and/or strengths often emerge with changing life circumstances” (543-44). Accordingly, resilience came to be viewed as a dynamic process, involving positive adaptations within contexts of adversity (Luthar et al. 543). Although closer to the operational definition of resilience argued for here, there remain a number of definitional concerns and theoretical limitations of the psychological approach; in particular, the limitation of positive adaptation to the context of significant adversity. In doing so, this definition fails to account for the subjective experience and culturally located understandings of ‘health’, ‘adversity’ and ‘adaptation’ so crucial to the formation of resilience. Our major criticism of the psychodynamic approach to resilience relates to the construction of a false dichotomy between “resilient” and “non-resilient” individuals. This dichotomy is perpetuated by psychological approaches that view resilience as a distinct construct, specific to “resilient” individuals. In combating this assumption, Ungar maintained that this bifurcation could be replaced by an understanding of mental health “as residing in all individuals even when significant impairment is present” (Thicker 352). We tend to agree. In terms of economic resilience, we must also be alert to similar false binaries that place the first and low-income world into simple, apposite positions of coping or not-coping, ‘having’ or ‘not-having’ resilience. There is evidence to indicate, for example, that emerging economies fared somewhat better than high-income nations during the global financial crisis (GFC). According to Frankel and Saravelos, several low-income nations attained better rates of gross domestic product GDP, though the impacts on the respective populations were found to be equally hard (Lane and Milesi-Ferretti). While the reasons for this are broad and complex, a study by Kose and Prasad found that a broad set of policy tools had been developed that allowed for greater flexibility in responding to the crisis. Positive Affect Despite Adversity An emphasis on deficit, suffering and pathology among marginalised populations such as refugees and young people has detracted from culturally located strengths. As Te Riele explained, marginalised young people residing in conditions of adversity are often identified within “at-risk” discourses. These social support frameworks have tended to highlight pathologies and antisocial behaviours rather than cultural competencies. This attitude towards marginalised “at risk” young people has been perpetuated by psychotherapeutic discourse that has tended to focus on the relief of suffering and treatment of individual pathologies (Davidson and Shahar). By focusing on pain avoidance and temporary relief, we may be missing opportunities to better understand the productive role of ‘negative’ affects and bodily sensations in alerting us to underlying conditions, in need of attention or change. A similar deficit approach is undertaken through education – particularly civics – where young people are treated as ‘citizens in waiting’ (Collin). From this perspective, citizenship is something that young people are expected to ‘grow into’, and until that point, are seen as lacking any political agency or ability to respond to adversity (Holdsworth). Although a certain amount of internal discomfort is required to promote change, Davidson and Shahar noted that clinical psychotherapists still “for the most part, envision an eventual state of happiness – both for our patients and for ourselves, described as free of tension, pain, disease, and suffering” (229). In challenging this assumption, they asked, But if desiring-production is essential to what makes us human, would we not expect happiness or health to involve the active, creative process of producing? How can one produce anything while sitting, standing, or lying still? (229) A number of studies exploring the affective experiences of migrants have contested the embedded psychological assumption that happiness or well-being “stands apart” from experiences of suffering (Crocker and Major; Fozdar and Torezani; Ruggireo and Taylor; Tsenkova, Love, Singer and Ryff). A concern for Ahmed is how much the turn to happiness or happiness turn “depends on the very distinction between good and bad feelings that presume bad feelings are backward and conservative and good feelings are forward and progressive” (Happiness 135). Highlighting the productive potential of unhappy affects, Ahmed suggested that the airing of unhappy affects in their various forms provides people with “an alternative set of imaginings of what might count as a good or at least better life” (Happiness 135). An interesting feature of refugee narratives is the paradoxical relationship between negative migration experiences and the reporting of a positive life outlook. In a study involving former Yugoslavian, Middle Eastern and African refugees, Fozdar and Torezani investigated the “apparent paradox between high-levels of discrimination experienced by humanitarian migrants to Australia in the labour market and everyday life” (30), and the reporting of positive wellbeing. The interaction between negative experiences of discrimination and reports of wellbeing suggested a counter-intuitive propensity among refugees to adapt to and make sense of their migration experiences in unique, resourceful and life-affirming ways. In a study of unaccompanied Sudanese youth living in the United States, Goodman reported that, “none of the participants displayed a sense of victimhood at the time of the interviews” (1182). Although individual narratives did reflect a sense of victimisation and helplessness relating to the enormity of past trauma, the young participants viewed themselves primarily as survivors and agents of their own future. Goodman further stated that the tone of the refugee testimonials was not bitter: “Instead, feelings of brotherliness, kindness, and hope prevailed” (1183). Such response patterns among refugees and trauma survivors indicate a similar resilience-related capacity to positively interpret and derive meaning from negative migration experiences and associated emotions. It is important to point out that demonstrations of resilience appear loosely proportional to the amount or intensity of adverse life events experienced. However, resilience is not expressed or employed uniformly among individuals or communities. Some respond in a resilient manner, while others collapse. On this point, an argument could be made that collapse and breakdown is a built-in aspect of resilience, and necessary for renewal and ongoing growth. Cultures of Resilience In a cross continental study of communities living and relying on waterways for their daily subsistence, Arvanitakis is involved in a broader research project aiming to understand why some cultures collapse and why others survive in the face of adversity. The research aims to look beyond systems of resilience, and proposes the term ‘cultures of resilience’ to describe the situated strategies of these communities for coping with a variety of human-induced environmental challenges. More specifically, the concept of ‘cultures of resilience’ assists in explaining the specific ways individuals and communities are responding to the many stresses and struggles associated with living on the ‘front-line’ of major waterways that are being impacted by large-scale, human-environment development and disasters. Among these diverse locations are Botany Bay (Australia), Sankhla Lake (Thailand), rural Bangladesh, the Ganges (India), and Chesapeake Bay (USA). These communities face very different challenges in a range of distinctive contexts. Within these settings, we have identified communities that are prospering despite the emerging challenges while others are in the midst of collapse and dispersion. In recognising the specific contexts of each of these communities, the researchers are working to uncover a common set of narratives of resilience and hope. We are not looking for the ’magic ingredient’ of resilience, but what kinds of strategies these communities have employed and what can they learn from each other. One example that is being pursued is a community of Thai rice farmers who have reinstated ceremonies to celebrate successful harvests by sharing in an indigenous rice species in the hope of promoting a shared sense of community. These were communities on the cusp of collapse brought on by changing economic and environmental climates, but who have reversed this trend by employing a series of culturally located practices. The vulnerability of these communities can be traced back to the 1960s ‘green revolution’ when they where encouraged by local government authorities to move to ‘white rice’ species to meet export markets. In the process they were forced to abandoned their indigenous rice varieties and abandon traditional seed saving practices (Shiva, Sengupta). Since then, the rice monocultures have been found to be vulnerable to the changing climate as well as other environmental influences. The above ceremonies allowed the farmers to re-discover the indigenous rice species and plant them alongside the ‘white rice’ for export creating a more robust harvest. The indigenous species are kept for local consumption and trade, while the ‘white rice’ is exported, giving the farmers access to both the international markets and income and the local informal economies. In addition, the indigenous rice acts as a form of ‘insurance’ against the vagaries of international trade (Shiva). Informants stated that the authorities that once encouraged them to abandon indigenous rice species and practices are now working with the communities to re-instigate these. This has created a partnership between the local government-funded research centres, government institutions and the farmers. A third element that the informants discussed was the everyday practices that prepare a community to face these challenges and allow it recover in partnership with government, including formal and informal communication channels. These everyday practices create a culture of reciprocity where the challenges of the community are seen to be those of the individual. This is not meant to romanticise these communities. In close proximity, there are also communities engulfed in despair. Such communities are overwhelmed with the various challenges described above of changing rural/urban settlement patterns, pollution and climate change, and seem to have lacked the cultural and social capital to respond. By contrasting the communities that have demonstrated resilience and those that have not been overwhelmed, it is becoming increasingly obvious that there is no single 'magic' ingredient of resilience. What exist are various constituted factors that involve a combination of community agency, social capital, government assistance and structures of governance. The example of the rice farmers highlights three of these established practices: working across formal and informal economies; crossing localised and expert knowledge as well as the emergence of everyday practices that promote social capital. As such, while financial transactions occur that link even the smallest of communities to the global economy, there is also the everyday exchange of cultural practices, which is described elsewhere by Arvanitakis as 'the cultural commons': visions of hope, trust, shared intellect, and a sense of safety. Reflecting the refugee narratives citied above, these communities also report a positive life outlook, refusing to see themselves as victims. There is a propensity among members of these communities to adapt an outlook of hope and survival. Like the response patterns among refugees and trauma survivors, initial research is confirming a resilience-related capacity to interpret the various challenges that have been confronted, and see their survival as reason to hope. Future Visions, Hopeful Visions Hope is a crucial aspect of resilience, as it represents a present- and future-oriented mode of situated defence against adversity. The capacity to hope can increase one’s powers of action despite a complex range of adversities experienced in everyday life and during particularly difficult times. The term “hope” is commonly employed in a tokenistic way, as a “nice” rhetorical device in the mind-body-spirit or self-help literature or as a strategic instrument in increasingly empty domestic and international political vocabularies. With a few notable exceptions (Anderson; Bloch; Godfrey; Hage; Marcel; Parse; Zournazi), the concept of hope has received only modest attention from within sociology and cultural studies. Significant increases in the prevalence of war and disaster-affected populations makes qualitative research into the lived experience of hope a vital subject of academic interest. Parse observed among health care professionals a growing attention to “the lived experience of hope”, a phenomenon which has significant consequences for health and the quality of one’s life (vvi). Hope is an integral aspect of resilience as it can act as a mechanism for coping and defense in relation to adversity. Interestingly, it is during times of hardship and adversity that the phenomenological experience of hope seems to “kick in” or “switch on”. With similarities to the “taken-for-grantedness” of resilience in everyday life, Anderson observed that hope and hoping are taken-for-granted aspects of the affective fabric of everyday life in contemporary Western culture. Although the lived experience of hope, namely, hopefulness, is commonly conceptualised as a “future-oriented” state of mind, the affectivity of hope, in the present moment of hoping, has important implications in terms of resilience formation. The phrase, the “lived deferral of hope” is an idea that Wilson has developed elsewhere which hopefully brings together and holds in creative tension the two dominant perspectives on hope as a lived experience in the present and a deferred, future-oriented practice of hoping and hopefulness. Zournazi defined hope as a “basic human condition that involves belief and trust in the world” (12). She argued that the meaning of hope is “located in the act of living, the ordinary elements of everyday life” and not in “some future or ideal sense” (18). Furthermore, she proposed a more “everyday” hope which “is not based on threat or deferral of gratification”, but is related to joy “as another kind of contentment – the affirmation of life as it emerges and in the transitions and movements of our everyday lives and relationships” (150). While qualitative studies focusing on the everyday experience of hope have reinvigorated academic research on the concept of hope, our concept of “the lived deferral of hope” brings together Zournazi’s “everyday hope” and the future-oriented dimensions of hope and hoping practices, so important to the formation of resilience. Along similar lines to Ahmed’s (Happy Objects) suggestion that happiness “involves a specific kind of intentionality” that is “end-orientated”, practices of hope are also intentional and “end-orientated” (33). If objects of hope are a means to happiness, as Ahmed wrote, “in directing ourselves towards this or that [hope] object we are aiming somewhere else: toward a happiness that is presumed to follow” (Happy Objects 34), in other words, to a hope that is “not yet present”. It is the capacity to imagine alternative possibilities in the future that can help individuals and communities endure adverse experiences in the present and inspire confidence in the ongoingness of their existence. Although well-intentioned, Zournazi’s concept of an “everyday hope” seemingly ignores the fact that in contexts of daily threat, loss and death there is often a distinct lack of affirmative or affirmable things. In these contexts, the deferral of joy and gratification, located in the future acquisition of objects, outcomes or ideals, can be the only means of getting through particularly difficult events or circumstances. One might argue that hope in hopeless situations can be disabling; however, we contend that hope is always enabling to some degree, as it can facilitate alternative imaginings and temporary affective relief in even in the most hopeless situations. Hope bears similarity to resilience in terms of its facilities for coping and endurance. Likewise the formation and maintenance of hope can help individuals and communities endure and cope with adverse events or circumstances. The symbolic dimension of hope capacitates individuals and communities to endure the present without the hoped-for outcomes and to live with the uncertainty of their attainment. In the lives of refugees, for example, the imaginative dimension of hope is directly related to resilience in that it provides them with the ability to respond to adversity in productive and life-affirming ways. For Oliver, hope “provides continuity between the past and the present…giving power to find meaning in the worst adversity” (in Parse 16). In terms of making sense of the migration and resettlement experiences of refugees and other migrants, Lynch proposed a useful definition of hope as “the fundamental knowledge and feeling that there is a way out of difficulty, that things can work out” (32). As it pertains to everyday mobility and life routes, Parse considered hope to be “essential to one’s becoming” (32). She maintained that hope is a lived experience and “a way of propelling self toward envisioned possibilities in everyday encounters with the world” (p. 12). Expanding on her definition of the lived experience of hope, Parse stated, “Hope is anticipating possibilities through envisioning the not-yet in harmoniously living the comfort-discomfort of everydayness while unfolding a different perspective of an expanding view” (15). From Nietzsche’s “classically dark version of hope” (in Hage 11), Parse’s “positive” definition of hope as a propulsion to envisaged possibilities would in all likelihood be defined as “the worst of all evils, for it protracts the torment of man”. Hage correctly pointed out that both the positive and negative perspectives perceive hope “as a force that keeps us going in life” (11). Parse’s more optimistic vision of hope as propulsion to envisaged possibilities links nicely to what Arvanitakis described as an ‘active hope’. According to him, the idea of ‘active hope’ is not only a vision that a better world is possible, but also a sense of agency that our actions can make this happen. Conclusion As we move further into the 21st century, humankind will be faced with a series of traumas, many of which are as yet unimagined. To meet these challenges, we, as a global collective, will need to develop specific capacities and resources for coping, endurance, innovation, and hope, all of which are involved the formation of resilience (Wilson 269). Although the accumulation of resilience at an individual level is important, our continued existence, survival, and prosperity lie in the strength and collective will of many. As Wittgenstein wrote, the strength of a thread “resides not in the fact that some one fibre runs through its whole length, but in the overlapping of many fibres” (xcv). If resilience can be accumulated at the level of the individual, it follows that it can be accumulated as a form of capital at the local, national, and international levels in very real and meaningful ways. 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